What are ‘Never Events’?

‘Never Events’ are, as the name implies, incidents affecting patients which should never occur. The NHS defines Never Events as ‘serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.’ Therefore, provided the guidance and recommendations are followed, there should be strong systemic barriers in place to prevent Never Events from occurring. That being said, Never Events do happen.

The NHS has identified 15 categories which constitute a Never Event. The list includes:

• Performing surgery on the wrong part of the body or operating on the wrong patient
• Incorrect blood transfusions or organ transplantations
• Incorrect placement of implants or prosthesis
• Foreign objects being retained in patients following a procedure
• Scalding patients

Clearly, these incidents sound inexcusable and may result in patients suffering serious injury or possibly even death, though this is not a requirement to be classified as a Never Event. 

The difference between Never Events and other serious incidents is that the former relates to systemic failings where guidance or safety recommendations are not followed, implemented or work. When a Never Event occurs, it acts as a red flag for the healthcare provider that there may be weaknesses in its current systems for ensuring patient safety. The occurrence of a Never Event provides healthcare organisations an opportunity to identify what went wrong, to review its safeguards in place and take targeted action to reduce the risk of reoccurrence. Repeated Never Events of the same type are signs that there are ongoing problems which need addressing.

The NHS stresses that Never Events are not meant to apportion blame on the individual healthcare worker. The aim is to constantly improve patient safety and therefore, it requires honest reporting when a Never Event occurs so that organisations can learn from its mistakes.

How often do Never Events occur?

Despite Never Events being ‘largely preventable’, they still occur every year. The NHS publishes its data on how many Never Events occur throughout 1 April – 31 March each year. Since 2015, there has been between 400-500 recorded Never Events every year, with the exception of 2020-21 when there were 364 (which may be related to the many cancelled procedures during the Covid pandemic).

Therefore, though the process of reporting and investigating Never Events is designed so that healthcare providers can learn from mistakes and improve its systems, it is concerning that the rate has remained largely the same. As the Care and Quality Commission stated: ‘about 500 times each year we are not preventing the preventable.’

In 2020-21, the NHS reported there were 12.8 million patient admissions and so the chances of a Never Event occurring is statistically very unlikely. Yet, Never Events do happen and sometimes with devasting consequences. For example, the NHS recently published its statistics on Never Events for 1 April 2022 – 30 June 2022 and among the most serious incidents was a lumbar puncture performed on the incorrect patient, wrong blood being transfused to a patient, and the removal someone’s ovaries when the surgical plan was to conserve them.

Causes of Never Events

The Healthcare Safety Investigation Branch (HSIB) published its report on Never Events in 2021. HSIB identified a number of reasons which contributed to the occurrence of Never Events, including:

• staff fatigue and low levels of staff arousal;
• staff not having adequate training to undertake the clinical task key to the Never Event;
• interruptions resulting in unintentional or missed actions during tasks; and
• performance targets which created pressure on staff to work quickly.

With the increased strain on the NHS through its ongoing workforce shortages, there is a real concern that the above factors may be exacerbated further, potentially leading to more Never Events.

HSIB recommended in its report that the National Safety Standards for Invasive Procedures is revised so that there is standardisation of critical steps before every invasive procedure. The NHS has taken this onboard and is in the process of revising its national guidance which hopefully will reduce the chances of Never Events occurring.

What happens if a Never Event Happens to me?

When a Never Event happens, the NHS is required to conduct an investigation into what, why, and how the incident happened, and what can be done to stop it happening again. Affected patients, families and carers should be engaged with at an early stage of the investigation, should they wish to be involved.

Those affected should be given the opportunity to ask questions and raise any concerns they have about what happened. The healthcare provider should share the results of the investigation and give the affected an opportunity to respond to the findings.

If you have been informed that there has been a Never Event involved with your treatment, you may be entitled to compensation. We have acted for those who have suffered serious injury following a Never Event and we understand the trauma this can cause patients. With our expertise in representing claimants, we can help you navigate through this extremely difficult time.

FURTHER INFORMATION

If you have any questions or comments about the topics discussed in this blog, please contact Filton Pavier or any member of the Medical Negligence & Personal Injury team.

ABOUT THE AUTHOR

Filton Pavier joined Kingsley Napley in 2018. He is currently a trainee solicitor in his second seat with the Medical Negligence and Personal Injury team, having completed his first seat with the Corporate, Commercial and Finance team. Prior to starting his training contract, Filton worked in the Medical Negligence and Personal Injury team as a paralegal. He assisted solicitors on a variety of cases arising from serious injuries to fatal accidents.